Tip: ICD-10-CM/PCS and bundled payments

by James S. Kennedy, MD, CCS, CDIP

Even though we now have a new president of the United States who vowed to abolish the Affordable Care Act, I believe that Donald J. Trump will not touch provisions that address perceived cost inefficiency or quality within our healthcare system.

In fact, if you’ve read CMS’ game plan for transforming healthcare published in Journal of American Medical Association in 2014, note that many of these provisions began with George W. Bush and have been embraced by the American Medical Association with the implementation of the Medicare Access and CHIP Reauthorization Act of 2015.

While not finalized at the time of publication, CMS is slated to further implement its game plan by imposing bundled payments for lower extremity orthopedic procedures, coronary artery bypass surgery (CABG), the initial inpatient treatment of acute myocardial infarction (AMI) that occurs during a cardiac inpatient admission, or percutaneous coronary interventions (PCI) with a principal or secondary diagnosis of AMI.

CMS will impose penalties or bonuses based on our performance with Part A and Part B spending targets during the initial inpatient stay and for 90 days post-discharge based on the ICD-10-CM/PCS-derived MS-DRGs as well as our performance on various quality measures, many of which are also risk-adjusted using ICD-10-CM/PCS.

Central to our success in these realignments is the proper application of ICD-10-CM/PCS-pertinent documentation and coding principles defines our cohorts and risk-stratifies their illness severity. If we are not complete and precise in our definition and documentation of myocardial infarction and its consequences or comorbidities, thoughtful in the interpretation of troponin elevations, and/or descriptive of our operative approaches during surgery, more than likely our imprecise or inaccurate ICD-10-CM/PCS codes will adversely affect our performance in this new environment.

Editor’s note: This article originally appeared in Just Coding. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Email him at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.